Topics in Geriatrics: Orthostatic hypotension in the older adult population.
Dizziness is an often subjective report for the cause of falls in the older adult population. One such cause of dizziness is orthostatic hypotension which is defined at a drop off 20 mmHg of systolic pressure or 10 mmHg of diastolic blood pressure following the transition from supine to standing (Lewis, 2004). It is worth noting that while there is an association between orthostatic hypotension and increased incidence of falls, the detection of orthostatic hypotension has not been proven to be a predictive factor for future falls (Liu, 1995). The assessment for this condition can be performed in only a few minutes and can be used to determine if interventions have been effective.
Objectives:
The objectives of this page are to:
1. Learn more about orthostatic hypotension in the older adult population.
2. Learn about indications for evaluation of orthostatic hypotension.
3. Learn how to perform an examination for orthostatic hypotension.
4. Learn about the risk factors for orthostatic hypotension and the risks it poses.
Information About the Test, Condition or Topic
Examination Procedure for Orthostatic Hypotension (CDC protocol) Prior to beginning testing procedure, inform patient that experiencing lightheadedness or dizziness may occur and be prepared to maintain patient safety.
Allow patient to lie flat for 5 minutes.
Measure blood pressure and pulse rate while supine.
Allow patient to stand up.
Repeat blood pressure and pulse rate after 1 and 3 minutes of standing
A positive test occurs when there is a drop of ≥20 mmHg in systolic blood pressure or ≥10 mmHg in diastolic blood pressure. Lightheadedness or dizziness is considered an abnormal response to position change and is also indicative of a positive test.
Patients with decreased tolerance for position change can also be evaluated at a sitting position after one minute before moving to the standing position.
When should I perform an examination for orthostatic hypotension?
Examination for the presence of orthostatic hypotension should be performed for patients who:
Are at risk for hypovolemia
Have had syncope or near syncope (dizziness, fainting)
Individuals are at risk for falls
Patients on anti-hypertensive medications or taking more than three medications
Evidence for Screening of Orthostatic Hypotension Epidemiological studies of orthostatic hypotension in older adults report varied prevalence from 4-33%. This condition has been associated with frequent falls, difficulty walking, and cardiovascular diseases (Rutan, 1992). There are many proposed causes for orthostatic hypotension including autonomic dysfunction, hypovolemia, metabolic and endocrine disorders, and low cardiac output (Rubenstein, 2006). Orthostatic hypotension may occur secondary to antihypertensive medications and has been associated with an increased incidence of falls in older adults receiving home health services (Lewis, 2004). In addition to external causes, older adults may be at greater risk for orthostatic hypotension due to decreased sensitivity of baroreceptors (Mayo). It is important for physical therapists to identify patients who may have orthostatic hypotension as it impacts patient safety and mobility and may require a referral for medical management.
Patients who test positively for orthostatic hypotension should receive treatment. Symptoms may be immediately decreased by returning to a supine position. Patients can perform physical countermaneuvers including leg elevation, co-contraction of leg muscles, and toe raising to increase return of blood volume back to the heart throughout the day. For long term treatment, compression stocking may help with conditions presenting as hypovolemia due to decreased return of fluid to the heart. Medication management may also be indicated requiring a referral back to prescribing physician (Figueroa, 2010).
Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med. 2010;77(5):298-306.
Lewis CL, Moutoux M, Slaughter M, Bailey SP. Characteristics of individuals who fell while receiving home health services. Phys Ther. 2004;84(1):23-32.
Liu BA, Topper AK, Reeves RA, Gryfe C, Maki BE. Falls among older people: relationship to medication use and orthostatic hypotension. J Am Geriatr Soc. 1995;43(10):1141-5.
"Orthostatic Hypotension (postural Hypotension)." Risk Factors for Orthostatic Hypotension. Mayo Clinic, n.d. Web. 04 July 2016.
Naccarato, Mary, et al. "Clinical Practice Guideline: Orthostatic Vital Signs."Emergency Nurses Association Clinical Practice Guidelines,(March) (2011).
Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35 Suppl 2:ii37-ii41.
Rutan, Gale H., et al. "Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group."Hypertension 19.6 Pt 1 (1992): 508-519.
Dizziness is an often subjective report for the cause of falls in the older adult population. One such cause of dizziness is orthostatic hypotension which is defined at a drop off 20 mmHg of systolic pressure or 10 mmHg of diastolic blood pressure following the transition from supine to standing (Lewis, 2004). It is worth noting that while there is an association between orthostatic hypotension and increased incidence of falls, the detection of orthostatic hypotension has not been proven to be a predictive factor for future falls (Liu, 1995). The assessment for this condition can be performed in only a few minutes and can be used to determine if interventions have been effective.
Objectives:
The objectives of this page are to:
Information About the Test, Condition or Topic
Examination Procedure for Orthostatic Hypotension (CDC protocol)
Prior to beginning testing procedure, inform patient that experiencing lightheadedness or dizziness may occur and be prepared to maintain patient safety.
A positive test occurs when there is a drop of ≥20 mmHg in systolic blood pressure or ≥10 mmHg in diastolic blood pressure. Lightheadedness or dizziness is considered an abnormal response to position change and is also indicative of a positive test.
Patients with decreased tolerance for position change can also be evaluated at a sitting position after one minute before moving to the standing position.
When should I perform an examination for orthostatic hypotension?
Examination for the presence of orthostatic hypotension should be performed for patients who:
Evidence for Screening of Orthostatic Hypotension
Epidemiological studies of orthostatic hypotension in older adults report varied prevalence from 4-33%. This condition has been associated with frequent falls, difficulty walking, and cardiovascular diseases (Rutan, 1992). There are many proposed causes for orthostatic hypotension including autonomic dysfunction, hypovolemia, metabolic and endocrine disorders, and low cardiac output (Rubenstein, 2006). Orthostatic hypotension may occur secondary to antihypertensive medications and has been associated with an increased incidence of falls in older adults receiving home health services (Lewis, 2004). In addition to external causes, older adults may be at greater risk for orthostatic hypotension due to decreased sensitivity of baroreceptors (Mayo). It is important for physical therapists to identify patients who may have orthostatic hypotension as it impacts patient safety and mobility and may require a referral for medical management.
Patients who test positively for orthostatic hypotension should receive treatment. Symptoms may be immediately decreased by returning to a supine position. Patients can perform physical countermaneuvers including leg elevation, co-contraction of leg muscles, and toe raising to increase return of blood volume back to the heart throughout the day. For long term treatment, compression stocking may help with conditions presenting as hypovolemia due to decreased return of fluid to the heart. Medication management may also be indicated requiring a referral back to prescribing physician (Figueroa, 2010).
Additional Resources for Health Providers
References